Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Wednesday, February 06, 2008

This is a public service announcement. You don't have to go to the ED if you have the flu. I just finished 4 of 5 days, and not a single day at any time were there less than 20-30 patients in the waiting room with cold and flu symptoms. Last time I checked, Wal-Mart has two entire rows of medicines that may or may not work as well as meds I may or may not prescribe for your self limited illness. Motrin, fluids and chicken soup go a long way. Yes, you feel bad, but your chances of feeling bad would have been less if you would have taken 10 minutes of your precious free time to get a FREE flu shot ( they were given free at several locations, or at some for $10). You are clogging the ED making me see sick patients in the hall ways with very little privacy. I actually had a 2 pack per day smoker tell me she couldn't afford generic Robitussin, and that she wasn't "in the mood for joking" when I told her she could hold off smoking just one pack and get some meds. POS waste of carbon. And another thing, don't just "hitch a ride" to the ED because your cousin is going. You are also clogging the ED. Wait times this past week and weekend have been many hours, and God forbid a really sick person gets lost in the fray of all this bull shit. Good for 911 getting out. And you jerk offs who come in 2-3 days after an MVA to get "checked out", after consulting an attorney (Johnny "beefcake" Edwards)-you suck cock. You waste my time and suck my soul. I hope you catch the flu from the others in the waiting room while you wait. Take some motrin at home and be glad you didn't really get hurt in your "accident".

I could go on but I'm too tired, so off the the litter box, and good lick cleaning, cough up a furball, and off to bed.

Side note: I went to the ED for the first time in years last week. My 19yo son fell while carrying a full garbage can to the curb and gashed his forearm at 9:45pm. Thanks to my clandestine reading of this blog and others, I was not looking forward to the trip. It turned out not so bad. An hour and twenty minutes later, having never seen a doctor he left the ED with 7 stitches and some glue. The PA was great.

The Bill? $975.00! $250.00 of that was my deductible. Unbelievable. I bet my insurance company and I paid for 2 or 3 of your dead-beat visits there.

I am so grateful for the existence of a flu shot; I've had asthma most of my life, and the flu makes it really scary. Fortunately, even when there are shortages, asthma patients like me get a priority, or I'd end up needing a respiratory therapy session. I tell people to get their damn flu shot, or I won't feel a bit sorry for them.

But then I get the ones telling me that they won't get the vaccination because it GAVE them the flu, which is just b.s.

I work in a more healthy area, so we need the colds to keep coming in to pay the bills. I prescribe the same Humibid I did in 1989 and an antibiotic unless I can reason with them. I didn't do an ER residency, but did do a month in my senior year. A grizzled attending told me 3 rules I still heed1: If it hurts Xray it (see rule 3 for exceptions)2: Noone ever got sued for putting some one on antibiotics3: All women get a pregnancy test.rule 3 was sort of a local variation, since 55 yr olds with ectopics were a not uncommon event

Personal experience with antibiotic misuse. Some 15 years ago my Aunt suffered a minor cat scratch, Fluffy was a known quantity, shots up to date etc. Against my better judgement I offered a medical opinion that it looked pretty benign and needed only bacitracin ointment for a few days. Of course, the next day she goes to the local doc in the box, gets a cephalosporin, and some days later C. Dificile colitis, which has required a fortune in vancomycin to treat. She still thinks I'M the jerk for not treating her on day 1.

Thank you for throwing some hate John Edwards way. If I ever hear that ambulance-chasing commie robot talk about how his dad was a mill worker again, my rapid blood pressure rise will cause blood to stream from my eye sockets.

Now that John Edwards has dropped out of the presidential race I'm waiting for a malpractice case to be filed against his wifes doctors. Seems pretty clear they messed up. She lost a breast and STILL has cancer. They don't need the $$$, but those doctors need to be taught a lesson or they'll keep malpracticing. I'm bein sarcastic, but a suit will be filed, mark my words.

Frank, antibiotics for a cold is bad medicine! I don't believe that "no one ever got sued for prescribing antibiotics"; we have an astounding number of ambulance-chasers out there who are always looking for their next meal. I have seen 2 patients with bad c. difficile enterocolitis after antibiotics, and 1 of them tooksome antibiotics she had at home for vague symptoms, without a doctor's evaluation. She ended up profoundly dehydrated, in acute renal failure, hypotensive, in the ICU.

I once reviewed a medical record for a defense attorney: the plaintiff had a AAA repair and then post-op complications, and was suing for the latter I guess. But the AAA was 9 cm, and found serendipitously at CT scan after he presented to an ER with chest pain and got the CT to r/o a cardiac contusion. I thought he was a lucky SOB, frankly!

About ten years ago I had a whiplash from a car crash. I got "checked out" right away because of altered consciouness and pain.

But I gotta tell you, I was never more unprepared in my life for the agony that came over the next few days.

Apparently you get worse before you get better.

So maybe have some mercy on the MVA latecomers.They may have believed they got away unscathed or with just some minor aches or bruises, but get alarmed when the pain and swelling begins to grow unexpectedly, instead of steadily receding like they expect.

Great rant. It has, indeed, been HORRIBLE lately in the ED with no less than 40 patients waiting at any given time. Yesterday, I had a 20 yo guy come in because he'd been diagnosed with influenza the day before, given Tamiflu, but still felt bad. What!?! Who is educating these people? Why is everyone so stupid?

Due to an egg allergy, I can't take the flu shot. Thus, I tend to get the flu - working in healthcare and being exposed to it frequently.

Nevertheless, I wouldn't dream of going to the doctor's office and certainly not the ED.

Which actually precipated an argument with my boss who wanted a doctor's note for my sick days. I told her if she wanted to pay for the visit, I'd go - but I wasn't wasting my money on a co-pay for a freaking virus.

Yes you will be sore. Any person that takes control of a 3,000 lb metal object, strikes another 3,000 lb metal object and is suprised that they are "sore all over" 1-2 days later is just that, an idiot. I have only seen 1 neck fracture that was delayed, that required emergent surgery, in a non drunk patient who came in 2-3 days later, and he was an idiot motorcyclist who laid his bike down without a helmet. You most likely have cervical strain, and even if you have a herniated disc, unless you are paralyzed, shitting yourself, or can't urinate you won't get an MRI in my ED. You will be referred for follow up, prescribed toradol and a muscle relaxant, and discharged. If you aren't drunk and broke your neck or can't move, you will know it IMMEDIATELY. Not after consultation with a yellow book attorney.

During my Internship I saw an elderly gentlemen there for "med refill". He produced a pill bottle with the hospital pharmacy sticker and "HT-21" in the line where the medication was supposed to be written. In those pre-internet days I went through every PDR and formulary with no sucess finding this strange drug, obviously some powerful chemotherapeutic agent or narcotic since it had no refills authorized. I even mentioned it offhandedly to a senior resident, in hopes his answer would tell me what it was. Finally, I called the pharmacy, something I still hate to do. Turns out, it was the Hospitals special placebo, only authorized for a few select patients. Ironically, where I trained was a short drive from Tuskeegee, another place known for its placebos. I did write a new prescription.

Shrodinger, this may be an Urban ER legend, but how do you defend yourself against the patient who comes in with the stupid minor neck sprain, leaves without an x-ray, then really does suffer a cervical fracture a few hours later doing something else stupid, shows back up the next day, now with a fracture. If you Xray everything that hurts, at least you can prove it wasn't broken the first time. Just bein a devils advocate.

CAT: Great Rant! Couldn't have said it better myself....in fact I think I have said it before.

Once (many moons ago before the "cock-sucking, bottom-feeding detritus-eating, low-lifed, scum-spewing, multi-goddamn-millionare John Edwards' types got wind of EMTALA) I actually got on the speaker to our waiting room and said, if you have the following symptoms.....you have the flu. We will be happy to see you when we can, but you might as well go home and get some rest because there's nothing we can do about it (this was before Tamiflu).

Wouldn't DARE do that now.

CAT, you don't practice too far from me, and I've been really surprised lately since we've been seeing a real variety of illness presenting with almost the same symptoms. We're seeing strep throat (our triage nurses swab throats...it's a long story, and subject for another post), Influenza A, atypical pneumonia, wierd sinusitis (I scanned some guy's head last night for the "worst headache" of his life in the left frontal area....and without any sinus symptoms, he had CT evidence of severe sinusitis.

So, my point is that I don't know exactly what's going on with some of these folks right now unless I do some investigation on the less obvious cases. It's wierd for it all to be out there at the same time. Y'all seeing the same variety?

I gotta add one thing to your rant (and to several of my previous rants too). Just because you're over 70, and you just "don't feel right" or "look right" is NOT an indication for you to be in the hospital! If your doctor won't put you in the hospital, quit calling 911 and trying to backdoor yourself into the f&*king hospital. We're not a goddamned hotel for old folks who "just don't feel good".

Earlier this week, our hospital was full. No beds available upstairs nor any coming available except for the occasional "celestial dismissal". We were holding 28 admits in the ER. Out of 41 total beds, more than 1/2 were admits. We pulled stretchers and chairs into the hallways to make space for 11 more patients, but we STILL had over 30 people in the waiting room. THIS SUX! I hate winter!

BTW, Dennis...I'm glad that your experience wasn't too bad. Here is the harsh reality though. Of the nearly $1,000 bill, only about $70 to $90 will make it's way to the doc. At least that's what happens in our system. In fact our average is $65 per chart.

'cat and erdoc85, same here. abso-fucking unbelievable. have you noticed... you too oldfart, that with the flu bustin' out all over that the schizophrenics are nowhere to be seen? just wondering. might be a good research project for someone smarter than me (i know that doesn't narrow it down at all).

Damnit 911, you just jinxed my shift tonight. I'd managed to avoid any crazies the last few. (except for the lady with "severe fibromyalgia" who got her Norco 10mg, Soma, and Valium 10mg, "stolen". Her PCP in a nearby town "couldn't" refill them since it "wasn't time for a refill yet"! "Then what the hell do you think I'm gonna do?" I asked..."give me some from your ER stock" was the answer!!!! I sent her quickly packing, and cursing my parents, but wish I had some of Frank's special pills for her. As I told her, it's always the people like you who seem to 'lose' or have 'stolen' your Rx. It's never the Amoxil Rx!).

I don't mind the whiny "my boyfriend left me" shit so much, I mind the $2,000 of useless lab tests and the 6 hours waiting to get a psych-fucking-chiatrist to call me back to transfer these "suicidal" idiots. (We don't have and I don't want a psych unit).

Then there's the argument with the psych-fucking-chiatrist about the patient. Yeah, I know the transfers are BS, but they have a 24 hour police hold placed on them, and I'm not "qualified" in my state to over ride that. (not to mention the CYA medicine here).

My favorite psych denial was because the patient had an elevated MPV (mean platelet volume) on the CBC and I couldn't explain it...hell, I didn't even know what it was!

If I get a BS psych patient tonight, I'm gonna "fart in your general direction".

The flu shot lady called my supervisor. I got written up for being “unprofessional.”

I was NOT unprofessional…my partner, my student and 2 cops backed me up on this. I argued with the supervisor and now I’m on paid leave. I thought: “Paid leave! He thinks this is a punishment! I’m actually going to sleep and get to spend some time with my fiancé. This is great!”

It turns out I only have part of tonight off. I have to go in at midnight. I still have to work from midnight tonight until fucking 0600 monday... AND every night next week…

The Navy Psychiatrists always tried to weasel out of seeing the few suicidal patients I thought needed their skills. They wanted us to get the patient to sign an actual "contract" where they agreed not to kill themselves, and we could actually get this contract from the psychiatry clinic. From my Perry Mason watching days I was pretty sure an illegal contract was unenforceable, so I made sure my name never appeared on one. I would just tell the Marine that suicide was a violation of the Uniform Code of Military Justice, and that seemed to work just as well as weeks of intensive psychoanalysis.

OK, 911 not too bad of a punishment. Last night I just had a drunk, high, bipolar guy with resolved right upper abdominal pain from last week sometime who wanted his "heart arteries checked out".

He was pain free when I saw him, maybe because he was fine to begin with, or maybe because of the 3 beers and 3 whiskeys (which he admitted to, there were likely more).

In any case, his biggest problem was the fact that he had shit himself and it dried all over his legs and feet (and also his sandals. Couldn't even undo the velcro since it was stooled shut).

He REEKED of cigarette smoke, and weed, drank like a fish, tested positive for coke and weed, had a cell phone covered in dried stool, and supposedly had bipolar illness (seems like that's the latest fashionable excuse for not getting a job)....but you guessed it....he "couldn't afford" a doctor!

NO personal responsibility....NONE. He even wanted US to clean up his dried poo! Can't wait 'til he take the cellular into AT&T and tries to get them to clean it!!!

Tried to call Hillary to clean him up, but the recording just asked for my credit card number.......

We had a patient the other that we transported - seems she took most of her prescribed Ativan and Valium in one sitting, an approximate total being 20 5mg Valium and 30 1 mg Ativan. She'd been released from one of the psych facilities up here 2 weeks prior to this episode for doing the same thing.

My problems with this are numerous: first, she's putting her husband through hell as he's been doing everything in his power to get her help (unless he's co-dependent in some way, which is possible). Second, she's got both Medicare AND Medicaid, which means I'm paying for the trips. Finally, our company has a policy of not refusing to transport - in this case it was obviously necessary as she was starting to have issues with her airway - but with many of the bullshit calls we get that the subjects (NOT patients, in those cases) do not require ambulance transport. Many of my peers relate this to being a case of "you call, we haul - that's all."

Where have you guys been all my life - I thought I was living alone in my oppositional defiant world!?! But... I'm here to keep you honest in the role of the ER Doc's best friend: the Hospitalist (aka ER ex-lax). Spending my days picking up the trash & refuse that makes it through that "steel curtain" of admission criteria gives me a slightly different perspective. Today I was called multiple times for influenza admissions - yet not one had pneumonia, a low sat, mental status changes, or even serious underlying issues.

In suburban Seattle (the land of hypochondriasis & Microsoft - and yes, they are inseparable) apparently we are admitting patients who are coughing (and have the flu) or feel horrible (and have the flu) or even have the dreaded fever (and have the flu). I provided some pointed educational tips to my young ED colleagues, "fuuuuck!" I haven't spent 16 years with my ass to the grindstone for this. I still love you guys though...

manchmedic: I affectionately refer to the case you present (with all of the Benzos) as an "underdose".

medicaster: Happy to have you aboard! Love the inseperapable connection between the computer folks and the hypocondriasis! Though I gripe about the stupid folks...and they DO make the best stories...I'd much rather take care of a stupid appreciative patient than an intelligent hypocondriac!

I hate internet patients (especially on those rare occasions when they're right and I'm wrong).

Most Internet Patients think they have bird flu or Ebola....when I think that they have a viral syndrome or sinusitis.

Sorry to medicaster for my fellow ERMD's admitting the flu. I've had to put a few octogenarians in house because they can't take care of themselves...but I refuse to admit young otherwise healthy people.